MEDICARE: EVOLVE LIFE CENTERS IOP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124735717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE LIFE CENTERS IOP LLC

Provider Business Mailing Address
First Line	:	2528 MOUNTAIN RD STE 204
Second Line	:
City	:	PASADENA
State	:	MD
Zip	:	21122-7204
Country	:	US
Telephone Number	:	443-548-3733
Fax Number	:	410-360-1675

Provider Business Practice Location Address
First Line	:	4231 POSTAL CT STE 201
Second Line	:
City	:	PASADENA
State	:	MD
Zip	:	21122-4474
Country	:	US
Telephone Number	:	443-548-3733
Fax Number	:	410-360-1675

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JESSIE COSTLEY
Credential	:
Telephone Number	:	443-548-3733

Provider Enumeration Date	:	11/02/2022
Last Update Date	:	06/06/2023

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